* = required fields

Intake Form – Individual Health Insurance
MaleFemale
YesNo
YesNo
YesNo
Household Income
Estimated Modified Adjusted Gross Income for the Current Year
Household = Tax filer + spouse + tax dependents
Spouse/Dependents
YesNo
MaleFemale
YesNo
YesNo
 
YesNo
MaleFemale
YesNo
YesNo
 
YesNo
MaleFemale
YesNo
YesNo
 
YesNo
MaleFemale
YesNo
YesNo
 
YesNo
MaleFemale
YesNo
YesNo
Employment Health Coverage
YesNo
YesNo
YesNo
Authorization
I have voluntarily provided the information on this sheet to BIFS, LLC, dba Baker Insurance & Financial Services to aid in the choice of individual health plan(s). I am pursuing their advice for health plan(s) that will best service my needs. I agree to receive my personal, no cost, no obligation recommendation, and I further authorize a licensed sales agent to contact me by phone, text, email, or mail, if needed. This information, provided to Baker Insurance, is not to be used for any purpose other than for my health plan(s) selection. I understand I am not bound to accept their recommendation. 

By returning this form, I am authorizing a licensed agent from Baker Insurance to contact me regarding my healthcare needs.


NOTE: When you click NEXT, you will be redirected to the Privacy Notice Statement to complete.

After waiting 10 seconds, if you are not redirected after clicking NEXT, click here.